tv Medicare Oversight Part 2 CSPAN August 18, 2014 8:58am-9:59am EDT
so unfavorable, they lost all of them. tell us about remanded and dismissed. >> the remanded, we do have some authority to send cases back to the lower level or to the quick if they, there is information that we need from them and that information's only available to, you know, from cms and its contractors. so we can do some limited remands. >> okay. part a that seems to be a very high percentage that's actually being remanded and coming back. do we know what happens then once they go back down to the second level, what occurs? >> well, actually, with most of these they have come back to us, and this large number was related to the part a/b policy issue which was resolved by cms through rulemaking, and so those are coming back to us. >> okay. so help us understand the order there. when you're talking about it's coming back to us and then it went to fourth level; it came back to you? >> yes. >> what does that mean?
talk us through how that happens. because this is a very high number here. as many are remanded as are found favorable, partially favorable and unfavorable combined. >> yes. and in these cases many of the judges decided to remand them. you know, they're basically questions about whether or not claims would be paid as inpatient claims you should part a or whether they would be paid as outpatient claims under part b. that was the basic issue. and so in order to get many of the judges felt they needed additional information in order to make that decision, and they sent these claims back to the lower level to get that information. what has happened as a result of cms' rulemaking -- and these cases are actually going to be coming back to us, and i think they have come back to us. >> okay. so they're remanded.
you got the additional detail, it's now coming back to you. how did that come up here on our statistics? what we're trying to evaluate is what's really happening in these cases. it's hard to be able to tell what's really going on. >> well, and we don't double count them, i think that's the important thing. they don't recount into our receipt levels when they do come back to us, you know? because they are not fully disposed of. the cases are still, still need an adjudication at our level. and so when they come back to us, we adjudicate them within the process, and then we would send them on. they either get paid or, you know, they don't get paid, and many of them are get appealed -- them will get appealed. >> okay. so i'm still trying to track this. they've gone through the first two levels of cms. >> yes. >> they come to you. >> yes. >> there's not the information you need, ip patient, outpatient, whatever it may be, you're remanding it back to cms. >> yes. >> they're getting additional
information, and then it comes back to you again? >> yes. >> so now there are one, two, three, four, five levels so far, excuse me, five different events within the first three levels. .. >> when it comes back to us, we adjudicated as all other claims, and we will have a hearing on it and make a decision. >> so this is somewhere around
60%, part eight around 60% being found fully favorable when they're coming to you. i expect they're remanded it's about the same percentage coming back act in? once they are remanded, basically if they are very, very persistent in part eight at least, pretty good chance they will be found fully favorable? >> i think if percentages whole trutholdtrue then you can use te percentages to say what will happen with the remand. >> that's approximately how long? getting to the first time, they have consumed three years in the process. then it gets remanded, goes back to see mess. they it in three months, whatever it may be and they're waiting back in line again, maybe another four years to get back in line to get to you. so a remand is an incredible amount of time. >> it's my understanding that these cases are really already back with us, that they were
sent back in bulk. so these are already back in the queue. but as far as how long that is, that's a number had to get back with you on. >> that's what we're trying to figure out. the remand is a number a somewhat we got last night. i'm trying to figure out if it's three years to get to you and a decision, goes back and if there back in the queue again so now we're up to six years minimum to get fully through all five of those steps. >> i believe, i will check on this for you and clarify it, but i believe they retain their spot in the hearing do when they are remanded. because -- >> they are right back to you again quickly? >> and right back into the queue where they were when they left us. because we haven't given up jurisdiction of the claim. we send it back for more information, but it's still with us. generally it would come back to the same judge who had it when it was sent, when it was
remanded. this year was an aberration. you can, you know, it was a very, very high number. we are not seeing that in subsequent years and we didn't see it in previous years. >> and you feel that's because of all issue of what's innovation, what's outpatient? >> correct. >> this is still with the two midnight rule and all that? >> yes. >> what a fun world. that's going really, really well. the hospitals loaded. >> we are waiting to impact it it will have at our level. we have not seen the impact at our level yet. >> i have yet to find a fan of that rule anywhere. that's one of the issues that doctors and hospitals rates consistently saying this affects our decision-making, but it wasn't your decision, i'm not blaming you. i would expect there would be quite a coming at you. they are secretary moniz amount of frustration around that rule. >> i think this is something that we are watching and need to
watch. we need to continue to see what the appeal rates are in this part a and part b inpatient outpatient arena. >> let me ask two more quick questions. i want to share this time as well. the dismissed and other. >> the dismissals are cases where for one reason or another usually it's because the appellant hasn't properly filed their request for hearing or perhaps they have abandoned their request for hearing in the process by not showing up for hearing and that sort of thing and so the cases are dismissed at our level. that is a final this position of those and less they appeal the dismissal. >> so that is an unfavorable based on the you didn't show, didn't follow, didn't complete the process. they started the process but didn't complete it. the previous decision would still stand which was unfavorable? >> that's correct. it becomes the final decision speed what is and other?
>> the other, i will actually -- escalations, it would include escalations to the medicare appeals council. as a nation we have about 100 hq does. occasionally we have an expedited judicial review but those are very, very rare. >> thank you. >> thank you. i'm still flummoxed by this remanded number. i just added up to fully favorable, the partially favorable and unfavorable, and came up with a number 21,846, which is nine from this 21,855. so this remanded number that you say gets back in the queue, are they getting back in fy '13 or they getting back in the queue in fy '14?
>> i believe that they came back in fy '13, for early this clear 14, right about the time that cms administrators issued a ruling is on this. spin but this number is so close and maybe that's just part of the aberration but that would mean virtually everyone of these cases was red because it will there was inadequate information. >> these are not come it's not a cumulative number. i understand that they are close to the same amount but theins es fully favorable, partially federal and unfavorable. it's a separate category. >> so the separate category which would mean that we're not talking -- were talking about close to 50,000 just in part a if you take all of these numbers and add together, give or take. >> yes. >> okay.
let me ask you this. aljs don't have medical training, correct? >> know. as a general rule they don't. i don't know whether there are any who i should have dual certification, medical and legal, but they are attorneys who have been selected often as -- >> because they have medical training, they are somewhat trying to determine whether or not a procedure was appropriate or not appropriate, correct? >> recently medically reasonable and necessary, yes. >> is the system flawed at the outset? >> well, we have some extensive training for them that is conducted. when they come on board we do a training session for them that goes over very much of this, but lawyers are involved in medical legal issues in many, many areas. >> abdicating typically for one
side or another and not judging whether something is appropriate medical procedure or not, whether some really needed this -- it's more of a philosophical question. obviously we've engaged in this for long period of time. i decided somewhat odd that in the end there are attorneys like you and me who have been trained a certain way but don't know whether this was an appropriate procedure or not. >> well but, in essence what they are doing is making a judicial decision that is based on the evidence that is going to pursue them. in our setting that includes the written record, the documentary evidence, and generally during the course of the hearing also some explanation of medical necessity from either a provider or supplier of the services.
and so that is, that's kind of the way the system is set up for us to be able to rely on the opinions of doctors. >> you can read your notes spent essentially it is a same thing i just, we look at the record to determine whether the coverage has been met. >> i think we are all troubled by the fact that 54%, or least that's the record we have heard, of the appeals in part a our sustained. you said earlier that the figure for the first part of this year is less than half that that are fully favorable but fully and partially to me need to be lumped together. what is the figure for 2014 for fully and partially favorable? >> i don't have a percentage for
that. >> could you get that for his? >> i certainly can. >> here's the dilemma i see. 54% of the appeals our sustained. so in the medical profession is never better than 50/50 chance of being sustained and you're going to appeal. so your volume is going to continue to increase as more and more providers recognize hey, this is a pretty good, your odds are pretty good. and when you have an alj who is looking at a set of circumstances, is not a physician but is trained, and is looking, well, from my perspective as someone who was not in the profession, it could be a close call. the procedure has been performed. it's not like there hasn't been a service that has been actually provide in most of these circumstances. so you're going to air in favor of saying okay, we're going to sustain this appeal.
so at some point i wonder whether we're diminishing returns here. that's more of a provocative question, a rhetorical question at this point. but i do think that the construct probably should urge us to think about whether it's the way we should be doing these appeals. >> i would like to clarify one thing here, which is the percentages you are looking at on the recovery audit, appeals. and the reversal rates on those appeals have been higher than the general reversal rate for the agency, which if it includes all appeals. so for 2014, and begin the numbers i have are fully favorable decision, but it was just 19.3%. the numbers have been -- i'm
sorry, that was fully favorable. i keep going to that number. i will get you a number on the reversal. >> the other thing i've been told is that when the same as actually is present at these hearings, that the decisions are not sustained, but the cms represented is oftentimes not present. so that suggests to me again that we have a system that isn't operating properly because we want fairness across the entire spectrum. so one provider shows up, has their appeal and the cms person shows up and it's not sustained, but another provider shows up, same circumstance but the cms person is not there and it is sustain. we are not providing equal protection under the law. >> let me -- the cms -- what we have found, and there's very
limited data on this and does come from cms, but when there's cms participation at the hearing, the reversal rate does go down. >> by how much, doing a? >> i think about 6% of our member quickly. it's from about 46%, only over a few months of data that we have, i'll get you the exact numbers, but from about 46% down to 40%. yeah, 40%. and as far as the reversal rates go, i've got that number now which is on the disposition. the overall, the overall favorable rate in 14 was 35.2%. we have been doing a number of things which have been designed to bring our policy interpretations in line across all levels and develop some consistency in education. part of that is training.
we have had approximately 20 planning sessions have been delivered by cms, their doctors, and their policy experts to the administrative law judges since 2010. and so what you will see if you look at the historical data is that the reversal rate has actually been going down. they were at a high in 2010, 55.5% fully favorable, and that is now down to 35.2%. >> why? >> i think the training efforts have a lot to do with that. >> a better quality of decision? they're dealing with every case in front of them, have to make a decision. so the question is, they cases coming to you, they even make better decisions at a lower level or there's something that's happened at the alj level with better trained that you're making better decisions than the
decisions earlier you find people fully favorable more often than what would be consistent or policy. >> or joint training leads to better consistency among the education level. >> at some point you get people making fully favorable decisions that should make partially or unfavorable, either better training a success that was it was an issue at some point that we are doing too many fully favorable or partially favorable. >> i don't think i would so -- i would go so far but it has improved. and i think the goal is, as congresswoman spear pointed out, the goal is to have the case paid if it is a legitimate claim to have it paid as early in this process as possible and keep them from reaching the alj level. >> trekkie may i add something? i just want to touch on this but is there training coming from you, the alj, back down to cms
feedback back to seem as? is seen as accepting that direct audit? i'm going to use an example that's happening, and orthotics industry where after an artificial limb is made and delivered to the patient, the claim is being denied because the actual word patient as an abt does not appear in the positions notes. but the word patient record artificial limb or prosthesis the. and the medicare history includes payment for the surgeon to conduct a limb amputation. and so many of these denials could be eliminated if when they get -- these are getting reversed at aljs, is the feedback going back down to the cms same look, just because the exact word does not appear in the surgeon's note that the patient is an amputee doesn't mean that you deny these. if you look at, it says the
physician is a saying they need a prosthetic and we pay them to amputate a limb. and so are you looking at different records? because, you know, -- >> no. by me, as a general rule we review the same record. there are some exceptions to that. it allows additional evidence to be present at the alj level but we are supposed to be deciding things on the same record. what does change the developers affect we do have a hearing, and so at our level we are able to question the provider, supplier, we see some explanation and then make a decision that becomes part of the evidence that is in front of us. >> my understanding is the auditors are not allowed to consider the omb professionals those but those are considered part of the physician's records initial on the physician's
record so the omb, the person makes the artificial leg, his notes, the auditors are not allowed to look at his notes to the only look at the positions notes. when you look, you look at them in entirety which includes the person, the process notes. is the feedback from you to cms to allow their auditors and a lower level to say, you need to look at the notes which are pushing these people in the system and it's ridiculous when someone is being, yo you know, something as simple as patient, and beauty is missing for the record for a guy who's been paid already. >> does. we do regular meetings with cms and their appeals group within cms. i think those happen on a weekly basis? weekly basis. when we identify a trend, we would bring that up at those meetings or if it was
significant trends, i would bring it up with marilyn tavenner. i'm not aware of the specific instance that you are describing. >> all, it's more than one. we have a 100 processes who have gone out of business in this country waiting to be reimbursed and i've gone out of business. so it's more than one. i am sure that we can get you a lot of those examples. >> if we become aware of them i think that's part of, part of the issue. our judges are individual adjudicators and so we have to become aware that there is a trend. when we do, we have those feedback loop is in place and we are able to do that. >> how do you spot a trend quick view of a system in place to forget to find of those trends? i see mr. meadows, my colleague of -- >> i just want to reiterate what the gentlewoman from illinois was talking about.
she is exactly right and this is not just unique to her particular group that has told a. we've got positions who literally go through step one and step two that have complete records. and it has to go to you before you look and say oh, gosh, it's a complete record and they waited, how many months or years to find it. and it's crazy stuff, ms. griswold. she's given that. i've got example to after this hearing we started hearing from all over the country from claims that were denied because the date instead of being at the top was at the bottom, or the physician, you know, had signed his name in this spot and they weren't taking -- i know we can't fix stupid but it seems like that's what we've got to do you because it's just, i mean, a reasonable person would do this. you talk about trends.
i don't know how you define trends because you've got an adjudicators who are educating across the omaha system. -- agitating. what one is in as a trend in his or her jurisdiction it doesn't work. and so i just got i appreciate the gentlewoman yielding to i will yield back. >> i just have one final thing and that is, as you go to meet with the newly confirmed secretary burwell, i was hoping that you would consider having a conversation with her about granting the same kind of relief from r.a.p. auditors artist of syncretic hospitals under part a to the work, under the two midnight rule to part b providers like those in orthotics and prosthetics, we will grant hospitals under part a, i think we need to consider granting it under part b especially since there's a whole
to the hearing at this point. thank you, mr. chairman. >> transported you want to jump in? >> thank you, mr. chairman. at the risk of quite frankly putting on now in the last couple of comments or statements, i had the same concern. i applaud that you've introduced a new initiative so that your productivity is better but now we are minimizing my information says, the averaging is now two hours, and given the complexities although we haven't talked about the complexities, we've talked about the easy stuff. i'm not sure it gets address. i know that given we now have an incredible backlog and we're struggling with this, it's time to do more than just for take out the steps, how we are touching these cases, how we are cross indicated, what the training looks like. we have to do something up front and the up front is nobody on this committee, and i daresay no
one in congress, is willing to tolerate waste, fraud, and abuse. we want you, everyone in the system to do everything you can, not just to minimize it, eradicate it. these are clearly administrative issues. while i do, i expect providers to be as administratively competent as they can, i can't with consistency, and i'm a lawyer, even read a medicare dob. given that, the likelihood that you make mistakes, simple, the form says that the date at the bottom of that form is updated issue. i've got 200,000 forms from last year and a set of throwing those away we'll just -- and no one pays attention to that. and the fact that we're doing this under waste, fraud, and abuse context, and i think that's important, but we are closing these businesses who are not going to be paid. there's a lot of small
providers. i know you've heard all this and we appreciate it, and i agree with my colleagues. i want fairness. is because you're a big provider, i don't think a big hospital system should have to wait and be penalized in this fashion, but what's critical in a rural and front just like mine in new mexico, that means an entire community and a place like a gallop where in my district, in torrance county, there are not any providers. there aren't any durable medical equipment providers, there are no small oncology providers, none. zero access. we don't even have the right tools or strategy to re-create these practices. so i'm interested as a result of understanding now the situation between how they are adjudicated, what you're initiatives are, how you're trying to many these cases. i appreciate the weekly meeting, but i would encourage you to go back to ms. tavenner and the
secretary and clear at least some of these comments, i think it seems like -- we've got a problem on the front and. so we do want updates, i do. i when information about what you're doing on the backend. and i want to be careful that people feel like because it's cumbersome that they can win on an appeal even when there might be a material problem. but i think the bulk of these cases, the reason we not happen in cases coming to you on a deal is because they are administrative issues that don't come anywhere close to fraud, waste, and abuse. we need to deal with that issue sooner than later. and i don't know that there's a comment to me back except i hope you take this urgency back because we are with all the work we've done to maximize access, this effort is minimizing it to the highest degree.
and it has a chilling effect on our patient population. >> i would certainly take that back. if there is a positive that is coming out of this situation, i think it is that the department is doing this workload more holistically. although there are three separate agencies, cms, omha, and the departmental appeals board and council, that work with these workloads, the department is taking an active role in trying to resolve things. and so i will take your concerns back. i certainly share them. i was -- i would also say i was very pleased when i came here to omha to be part of an agency that has for the most part met its 90 day time frame. as administrator myself i find the delays very troubling and unacceptable.
you basically have here though a workload and capacity problem speak but can we get to that for a moment? i mean, we can sit here and complain for hours, and nothing is going to change. because the addition of 17 new a lj is, talk about -- aljs. talk about the simple math that was referenced. there's 500,000 appeals that would be backlog by the end of this year. you divide that by 1220 and you're working at optimal levels and i don't know that you could do any more than that. frankly, i do know that we want you to do more than that because giving less than two hours to every case is probably unfair and would be slipshod. that would suggest we need 410 new aljs if we wanted to get rid of that backlog in a year. 410 and you have asked for 17.
or you have given 17. so we're basically saying to all the providers out there, suck it up. excuse my language but that's basic we what we're saying to the but we are saying that we are not willing to deal with this backlog in the reality that we are putting blinders on, we'll add a few more and cross our fingers and hope that with a few new reforms that you put in place, that is not going to reduce it, will not be back next year with the same discussion. so how would you comment to that? >> there are several things. one, -- >> i'm sorry to interrupt. could you pulled your microphone or little closer to? thank you. >> you know, there are several funding issues here. and in my mind one of the primary ones has to do with the
recovery audit program and the recovery audit legislation. i think when congress passed the legislation for the program it was envisioned the program would be so funding out of recovery. but the legislation actually provides that the administrator cost of cement will be covered. that does not include the administrative costs over the, of omha or the administrative cost to the departmental appeals board. so what we have basically had in that regard is a workload that came in on us that was basically unfunded. so i think that's part of the problem, and it's a part of the problem that i think does have a solution. and so if i were queen for a day but yes. >> that would be one of the simple fixes that i think would be possible.
>> meaning what? >> to in some way properly fund, funded omha and i will put in a plug for my sister agency, the departmental appeals board, so the recovery audit appeals that come to the last two levels are funded out of the administered costs are funded out of the program and they are at the lower two levels. >> so is there enough money that is recovered to pay for all of the levels of appeal speak as yes, i think that there is, yes. this is based on cms's reports on the recoveries that are coming from that program. >> so that is one part i think of the solution. there some other things as well. we are doing these coupons can what involves alternative
adjudication models. using a settlement conference facilitation. if the pilot is successful i think we need to look at some things like that as well. >> where is that being piloted? >> is being piloted at the office of medicaid hearings and appeals. there's the geographic location. it's being done with part b i believe. yeah, part b claims right now. there's a certain time period where we are offering the facilitated several conferences. cms -- >> give us an example of what that means. real-life terms. >> real-life terms, and it was put on our website on june 30 so it's a very new program and we are waiting to see a balanced response to it. but the theory is that an appellate will be able to come in and ask for a settlement conference with an attorney who is at omha.
cms would provide someone better with settlement authority who would be able to discuss merits of the claim and possibly resolve them to ensur ensure thy in the queue encoding. that is the theory. while that is going on they do not lose their place in the hearing to. so they were still remained there. but we're hopeful that this will allow us to resolve some of the pending claims. this is a two-part problem. there are the pending claims that we have. there are also the receipts that are coming in. this piece of the solution is designed to do with the pending cases that are already with us. >> is it your assumption slamdunk cases go back to mr. mehta's statement about signature in the wrong spot and they walk in and say it's not at the top, is at the bottom. is at your assumption it would be that kind of stuff coming at you? what is your assumption with a settlement? on the syllabus a lesser amount than fully paid, or is it fully
paid, at a faster process? >> i think it depends. like most settlement conferenc conferences, it's going to be probably a little bit of give and take. that would be my anticipation but if it's something that we can come in the course of which really a prehearing conference with an attorney, point out a simple error, a tactical air or something like that in these claims, then it is potential. it is possible they would be fully paid. we would have to wait and see how that would work. >> so the alternative dispute resolution would be valuable to providers in particular it was a decision that was going to be made with -- >> yes. >> so that becomes the appeal. >> we are trying to find the way of resolving claims within our pending workload more quickly than we can get them to an alj. we're trying to do that given
our current authority. right now the way the statutory scheme is structured, and appeal cannot get out of step three. they cannot leave omha without action by an alj. so what this would do, they would be this agreed upon settlement, both parties would sign and the judge would then dismiss the appeal. said the agreement becomes the resolution of the claim. >> is that listed in the chart you gave us as a dismissal? long-term or -- >> it would end up being, it would probably be a dismissal but right now we're just tracking them separately as a settlement resolution. >> the other alternative is global settlement discussion concept, which claim it's that have very similar kinds of cases
would all be invited to come in and participate in a global settlement but they could just not to i gather, is that correct? >> this is an initiative that is one of cms' initiatives, and i have to admit that my knowledge on this is limited. but it's my understanding that it would be a global settlement. >> so that what happened before it even got to? >> i think it also contemplates, they're also looking at claims pending at all levels of the process. >> we haven't seen it operational you? >> no, we have not. it's an initiative. >> i know you're committed getting back and forth with cms and cms is part of the issue. i get that. that's not you. but you have these regular conversations. what we are getting to an attorney help them try to do a type of pre-settlement, that's
something that they would have rather had with cms, face-to-face with someone there, resolve this or to get on the phone and other looks at the same document and tries to resolve this. it's a simple, straightforward cases. they just want this resolved. if they are a physical therapist that is shy to take care of its practice as will trying to do all the paperwork, he does not need one more thing to do. to try to chase all this stuff down. to be able to leave and to do hearing and be in the process to hire outside counsel as well beyond what they want to build to do. they just want resolution of simple things. how could a process work in a cms so it never gets to you? we are still can't figure out how do we prevent the backlog? >> right. i think amongst cms' initiatives you will see mention of a discussion period, particularly with regard to recovery audit. and i think that that could be
helpful in resolving these claims out of the lower level. >> but that's something they're discussing but that's not something that they do currently? >> i, i really can't speak to that. i don't know to what extent they have a discussion period right now. >> i am informed it is optional right now spent at the cms level they can do discussions as well? >> i think so but i will have to check on that. i would rather get back on of cms get back to you on this. >> i understand. we're just trying to do some fact gathering as well. again we come down to the issue of they just want resolution. once the contractor grabs it,
files, lays it out, they lose contact another fight with someone else. they're fighting with the folks they can't get to anymore. because it's too late. that made the decision and have filed it and the opera is on to figure out, playing the percentages literate if they grabbed 10 or 15 they know they'll get three or four of these alleys, get paid a percentage of each of them. it's a whole different game for them. but for the provider, our issue all along is if it's fraud, it's fraud and we ought to bust them. if it's a good provider, there should not be -- these are the folks we need on our team and that the american people need rather than hurt. >> i fully agree. and i think that identifying not just medicare fraud but also improper payments is an important piece of this puzzle. but what we have done i guess nsls efforts to implement
congress goes -- congress' intent in that regard it is gotten out of balance. what we need to do is restore that balance at this point between the fraud efforts and the appeal rights. and so i have spoken with the secretary on these issues and the note she is committed to restoring that balance. >> you know, i had an auditor in my district that was great a great deal of discomfort for one of the hospital providers in my district. and is also a hospital those under and about the financial pressure coaches keep its doors open. my experience with that particular situation suggests that more than anything else, the provider wants to know what's going to be approved. they could, in fact, have been unbundling services that would
allow for more reimbursement. i don't remember the elements but sometimes the providers are in the buying and are looking for ways to up code or to unbundle services. so we need to be smart about this and not that big be taking one side or another. everyone should be treated the same but it's so important for there to be some certainty and some finality and sometime in his to these decisions. and this backlog, i keep coming back to this backlog. we are not getting anywhere near addressing that even with all of these new proposals that haven't even been tested really. so i still think that whether we higher temporary aljs for a period of one year and deal with this backlog, otherwise we haven't really accomplished mu
much. >> and just to address that, there are very, very limited authorities for hiring temporary aljs. and its statutory under the administration's procedure act, really there are two ways. you can try to get a loan, a judge on loan from another agency. most agencies have their own backlogs and only when requesting loughner judges and we did not get any. the other way is to our judges who have retired and they are called we hired senior aljs. those individuals are also on the list that is maintained by opm. they can be hired for a couple of years and then let go. beyond that and alj appointment is, you know, essentially a life appointment. except for removal for good cause after hearing before the board. >> how large is this list of
retired aljs? >> it's probably around 100. it's not a tremendously long list. you know, but we do have that. we requested it in april because we do think that temporary capacity is a part of this solution to deal with the backlog. now, when you're talking about protective receipt levels i do think we need to be a properly staff for what we anticipate to be coming in. >> so i don't know if that's helpful, but aljs aren't non-probationary when you hire them under the aca. there's no probationary period. there are no performance reviews, and they can't receive awards. so those are kind of the things that make them different from other government employees.
>> if the gentleman would yield, i want to follow up because they're hitting on precisely the point, is why it's so incredible important here today, that it really is about what's coming to you. at how do we address that. the bigger concern that i have is even when you're hired, 100 it will still be shy based on my simple math of what's going to happen. this doesn't stop to become is growing exponentially every day. i think it's 1500 appeals at least a week. is that correct? >> it has been as high as 16,000 appeals a week. it has been down slightly at the beginning of this year to 11,000. we are trying to figure out where the plateau is going to be. >> well, i guess i was told by jonathan blum before he left that there was a policy change
within cms that was initiated and made -- may be numerous policy changes but there was a policy change between 2011-2012 that dealt with the way that they start to refer these to you. part of it is rac, and he needed a legislative expect my question to him was, if there was a policy change why do you need a legislative fix? but what i'm concerned about is, is what changed in 2011 or 2012 to make this number grow that you are getting when we are not seeing payments, improper payments actually go down. so we have seen that progress in terms of improper payments and yet we have this huge problem on her hands and we are not saving any money. so what changed in 2011 or 2012? i would yield back to the chairman.
>> well, the big thing was the recovery audit of course. talked about that. that was initially a pilot program. we saw i think it was four states, and speed that that was an act of congress. he indicated it was a policy within their agency that, i don't know if -- >> and it's probably, i mean, there was, and he was probably around that time period where there was a focus on identifying improper payments. that's not tracked as part of our, we track the recovery audit separately, but cms' effort to identify improper payments, zone program integrity contractors, and others, you know, programs that were looking at fraud issues, and there was also a coding initiative and some other things like that. but any time there are efforts
at cms' level that result in denial of more claims, then at our level there's going to be an increase and appeal. >> that's my point. it didn't change the improper payment. they may have done that and it may been well-intentioned, but we are still actually increase, if you look at the numbers you can go on there. we had a hearing yesterday so that's fresh in my mind. but i will yield back but i want to thank the ranking member and the chair for their leadership on this. >> and if i -- >> go ahead. >> could i go back to one issue you raised earlier, which i think i have finally kind of grasp what the question may have been. and that has to do with our appropriation and how that is handled. and, of course, as you pointed out the medicare modernization act did contain language which
would authorize the appropriated funds that would cover an increase. having said that though, that appropriation still has to be approved. and it does have to go through our department appropriations process. so i just wanted to point that out. i would also say with regard to our general appropriations that we do know we've been living in challenging budgetary times, and in the past five years the president's budget has actually only been approved for us in one of the five years. so requests that we have gone forward with, even though they would be somewhat modest, have really only been approved this year. so we appreciate that. we are trying to do what we can with the money has been appropriated to us.
>> and that was approved because as part of the omnibus bill? >> oh, was it part -- >> why was approved this year? >> i don't know whether was part of an album this bill or what it was part of but i do know -- omnibus bill. >> is there any other statutory authority you think you need or could use? >> or solutions we have proposed? >> you know, i think that are a number of things that are going to be coming through the appropriate legislative process that we're looking at. at. i think that you that i have highlighted from our perspective will provide us with the greatest ability to handle our workload and to expand the we waved -- the way we educate at omha. there are some additional things that are being considered
through the departmental workgroup that i know will be coming up through the proper legislation channels. >> when will you evaluate the process? you obviously just started june 30. when is your target date? is it a year, six-month? >> we are looking at a six-month evaluation. >> can you put us on a calendar reminder six months rest and get to this committee as well? >> certainly. and we are tracking metrics with a from which we will judge the success of the program. we would be happy to include your. >> these do. this committee is obviously very interested in that. >> tried to i don't have any further questions. i want to thank ms. griswold for being so attentive to her questions and for sitting around for an hour and half while we went and voted. and thank you for your service to our country. >> i thank you for your interest in this issue. it is certainly one near and dear to our hearts as well. >> it is near and dear to a lot
of people in her district. not only want to do with fraud and waste and improper payments which is a more direct one, but also to providers that absolutely firmly intensely hate the rac audit process. when they go through it and there's a signature in the wrong place or a date in the wrong spot and they just want to get it resolved, it now takes three years to get it resolved, tops. so goes from there frustration from rac to frustration beginning an obvious solution. that doesn't help any of us. finding solutions to what you're proposing that they could go through the process, if you don't like it, if you don't like what happened in the summer but they still are in the queue to have it resolved, rv speak they are actually in the queue. there's nothing mandatory about that settlement process. at any point they can exit the process. >> they just want an answer.
so that's -- >> they are entitled, i realize. >> that's a key thing. if you're working on process to do that, thank you. continued to press. if there are ways we can help, because as ms. speier mentioned, bringing on more aljs is not going to solve this. there's no way you get 400 more aljs so there has to be another solution to this and determine how do they get answers. part of this we understand well is on cms. you should not have the numbers hidden from you. so if you have, and looking at these percentages and i know we've kicked around numbers but let me mention this one of a number. when i look at the percentages i pull out the remanded because those are coming back. that's a different number i pull out dismissed because they're not getting the. when i look at that fully favorable and partially credible just report a, i don't know where the other numbers, showing 65% either fully favorable or partially favorable resolution
for them if they get to you. that's telling me the job is not getting done on the cms site. you should not have that high of a percentage of overturned getting the. there is something being missed. so part of the issues we've got to press on cms to get things resolved before the every day to you so you don't have a backlog of this i. just as physical you should not have a 65% overturn rate. to be able to get to you. so that's not on you but i'm just saying publicly there are issues on the previous to that we've got to get results. anymore comments? thing to for spending a day and we apologize for the long delay. with that we are dismissed. [inaudible conversations]
>> here's what's ahead today on c-span2. next a reason supreme court oral argument, greece v. galloway get with the legality of prior open public meetings. then we'll show you all of today's "washington journal" program again and later we'll show you that hearing on medicare oversight once again. >> here's a look at our primetime lineup for this week on the c-span networks.
>> next the supreme court hears oral origin in the case of greece v. galloway, and issue the legality of open public meetings with prayer. the justices are from both sides for about one hour. first some background on the issues involved. >> on november 6, 2013 the supreme court heard the oral argument in the case account of greece v. galloway, a town a new city. to residents objected to the town board beginning most other meetings with predominately christian prayer. joining us is mike doyle who is a legal correspondent. what of the going to hear? what issues speak with will have the conflict between the right of peoples not have religion a post up on them by the state versus the desire of town leaders in greece, as city of
96,000 souls, to invoke the lord at the start of each of their sessions. so there is this conflict between legislative prayer which is something that is common to many political bodies and the first amendment's guarantee against the establishment of an official religion. the two people in the case, one is an atheist, one didn't profess a religion. they objected to most of these meetings began in greece with a christian prayer, but? >> right. between 1999-2007 when the case was brought, every single one of the legislative prayers was led by christian miniter. some are quite explicit talk about our lord and savior jesus christ. so the belief of the citizens who objected it was bad this is far too emphatic an endorsement of christianity and they would want to open up and make more generic the phrase. >> is this the case for one of the justices mention the court itself against the session with
a prayer or a moment's? >> indeed. and the fact foreshadowed what would happen in the eventual decision as, we'll see what happened in the decision but it is the case that many political bodies of the country as well as legal bodies, there's indication of god state or maybe the lord shed his grace upon us. >> let's take a listen. >> we will hear arguments first this more in case 12696, a town of greece v. galloway. mr. hungar speaks thank you chief justice and may please the court. the court of appeals directly held at the legislative prayers at issue in this case were not offensive in the way identified as problematic in march. by the court and committed legal heir by drafting the endorsement steps onto marsh as newberry to the practice of legislative prayer spent i'm wondering what to think of the following? suppose as we begin this session